Pakistan has tremendous talent, what we need it to select right
people, put them at right place and provide essential infrastructure
We need to highlight our research work which the
NICVD faculty is doing- Prof. Tair Saghir
3rd Pakistan Heart Valve Cardiac Imaging Summit 2025
KARACHI: Keeping up its past traditions National Institute of Cardiovascular Diseases organized its 3rd Pakistan Heart Valve Cardiac Imaging Summit 2025 on Saturday May 17th which attracted interventional cardiologists and imaging specialists from all over the country. Prof. Saba Bhatti Chief Organizer and the Course Director had finalized an interesting scientific programme. The speakers included experts from Pakistan besides guest speakers from overseas who made presentations through Video link. An interesting debate on TAVR vs SAVR participated by Prof. Bashir Haneef Chief of Cardiology at Taba Heart Institute and Prof. Saulat Fatimi an eminent cardiothoracic surgeon from Aga Khan University Hospital was one of the salient features of the Summit, not to forget the excellent local data presented by Prof. Abdul Hakeem, Prof. Saba Bhatti, Prof.Babar S. Hassan from SIUT and Prof. Shahid Sami another noted cardiac surgeon.
Prof. Nadeem Qamar, Prof. Tahir Saghir former and present Executive Director of NICVD respectively chairing the first scientific session along with other distinguished guests during the 3rd Pakistan Heart Valve Cardiac Imaging Summit 2025 organized by NICVD on May 17th 2025.
Eminent cardiologists and imaging specialists who were invited to chair different sessions and for panel discussion also made useful contribution to the scientific deliberations. Of course, the concluding remarks by Prof. Abdus Samad regarding TAVR and SAVR was not only informative but timely, instructive that we need to embrace the new technology and make the best use of it for the betterment of the patients. Yet another interesting debate was on safety and efficacy of PMBC in Mitral Stenosis in which Prof. Jawaid Akbar Sial and Dr. Hafizullah Boggio participated.
Prof. Tahir Saghir
Prof. Nadeem Qamar former Executive Director of NICVD who has played a vital role in transforming the NICVD to one of the best cardiac care facilities in the world speaking in the inaugural session remarked that he has always asked the speakers to present local data and look at it from local perspective. Their acceptable mortality figures should be much less than the centers overseas since their number of cases are not much.
Dr. Mouaz Mallah
Later talking to Pulse International, Prof. Nadeem Qamar said that our problem is that we need to select the right people, put them at the right place and provide them much-needed infrastructure. That is what I did and one can see the results. There is no dearth of talent in Pakistan, once facilities are provided to them, they can-do wonders. We can see the academic stature of NICVD has improved a lot and now the faculty is publishing their work in world renowned journals like Journal of American College of Cardiology, he added.
Prof. Tahir Saghir the current Executive Director of NICVD in his brief address stated that lot of work is being done at our institution, variety of procedures are being performed and our work speaks. However, we need to highlight the research being conducted by the faculty at NICVD for which appropriate measures will be taken, he remarked.
Prof. Abdus Samad along with Dr. Zahid Jamal, Prof. Abdul Hakeem, Dr. Osman Faheem, Dr. Rizwan and Dr. Amin chairing one of the sessions during the Pakistan Heart Valve Cardiac Imaging Summitt 2025 held on May 17th 2025.
Scientific Sessions
Dr. Mouaz Mallah was the first speaker who discussed Nuclear Imaging in Valvular Heart Disease and highlighted its usefulness in diagnosis of Endocarditis, Microvascular Dysfunction and Valve Degeneration. He also referred to the guidelines by American Society of Nuclear Cardiology. This, he opined, is an emerging topic. He discussed in detail coronary microvascular dysfunction, Fibrosis, Myocardial remodeling/response, Myocardial blood flow in in Aortic Stenosis, Amyloidosis and Aortic Stenosis which is seen more in females and less in males. For correct diagnosis Dr. Mouaz Mallah opined, one needs good clinical scenario. Echo, he stated should always be the first and not the last. He then showed some informative PET endocarditis slides and discussed complications of endocarditis. His advice was that one should always look for local complications. Prosthetic valves have 86% sensitivity and 84% specificity. Speaking about the limitations of PET Scan he said that it could give 15% false positive results. He also talked about 2023 DUKE-ISCIDC imaging criteria. There are multiple new applications of nuclear cardiology in valve disease.
Commenting on the presentation Prof. Saba Bhatti the Course Director remarked that in Pakistan, nuclear cardiology is covered in radiology. Gap in training is yet another problem. She suggested close collaboration between radiologists and cardiologists. Dr. Sajid remarked that unfortunately in Pakistan there is not much advance in nuclear cardiology. Dr. Mallah said that there is a learning curve. Nuclear cardiology is extremely useful in prostate cancer.
Prof. Abdul Hakeem
Dr. Omar Khalique from United States was the next speaker who in his presentation discussed Transcatheter Valve Replacement & Electrosurgery. TAVR, he said is the focus of degeneration. Patients may improve with anticoagulation. He then discussed management of a few cases, showed full work flow of a patient, discussed TMVR. He also showed the LAMPOON-TMR procedure and highlighted the successful results of TTMR. He gave a few Tips for anatomic orientation and showed some procedural imaging slides. Better TEE imaging slides were depicted. This procedure Dr. Omar Khalique remarked was good for routine to complex cases.
Prof. Saba Bhatti
Dr. Sukoon Gurmani from NICVD spoke about unmasking the unexpected multimodality imaging of Aortic Valve with coexisting pathologies. She discussed the management of a few cases and highlighted efficacy of multimodality imaging. The prevalence of Sub-Aortic stenosis was 6.5%. This approach is ideal for intervention. In difficult aortic valve diseases multimodality imaging provides accurate results, she stated.
This was followed by an excellent presentation by Prof. Abdul Hakeem on the Landscape of TAVR/structural heart disease interventions in Pakistan which raised many questions. There are thirteen functional centers in Pakistan, eight centers have about twenty-five people. To get acceptable results, one must do at least twenty-five cases in a year. Centers doing TAVR needs to be accredited. At times patients go for TAVR without seeing the cardiac surgeon which is not desirable. TAVR, he opined, must be done only in high-risk cases.
Low risk cases are not candidates for TAVR. Only 50% of these centers have an appropriate Heart Team and it is not legal to do these procedures in such situations. In some cases, Table mortality in TAVR accounts for 40%. One can come across coronary obstruction and patient can suffer from stroke as well. In hospital mortality is usually low. Knowledge of anatomy is essential otherwise one cannot predict complications. Surgical team was standby in 70% of cases. High cost is the major problem. We lost twelve patients waiting for TAVR. All suitable cases should be operated by surgical team as health economics is very important in countries like Pakistan, he added.
Prof. Khawar Kazmi along with Prof. Col. Sajjad Hussain and Dr. Azam chairing one of the sessions during the Heart Valve Cardiac Imaging Summitt 2025.
We started TAVR Registry in Pakistan but it has not made much progress. People are afraid of making eateries or say they forget to make entry. Some even do not trust. A seventy-five years old patient must see the surgeon. How to maintain the quality of the programme is a challenge. Fellowship programme should consist of at least one hundred cases and one must do at least twenty-five cases annually, he added.
Debate on PMBC
This was followed by a debate on the safety and efficacy of PMBC in Mitral Stenosis with a High Wilkin Score. The speakers included Prof. Jawaid Akbar Sial and Dr. Hafizullah Bughio.
Prof. Jawaid Akbar Sial stated that for rheumatic mitral stenosis, medical therapy, PTMC and open-heart surgery are the options. MVR has many problems as compared to PTMC. Indications for PTMC are expanding. There are many grey areas in Wilkin’s score and it has certain limitations. At the NICVD so far, we have done 258 cases during the last nine years. PTMC can be successfully performed in patients with high Wilkin’s score by experienced persons. Mitral Valve replacement in pregnancy requires anticoagulation while PTMC is good which is being done at many centers.
Prof. Bashir Haneef
Dr. Hafizullah Bughio from Taba Heart Institute mostly agreed with Prof. Jawaid Akbar Sial’s point of view but hastened to add that increased risk is of complications is a problem. At times there is resistance in balloon expansion besides PMBC success is low in high score. He also referred to its limitations. PTMC complications include bleeding, infection, hematoma. It is a good procedure but should be performed in selected cases. Careful selectin of patient is very important.
Prof. Saulat Fatemi
Prof.Jawaid Akbar Sial responded by stating that during his recent visit to NICVD Satellite Centre in Sukkur he was able to do twelve cases in a day. Do not do it in congenital heart disease and do not follow the Wilkin’s Score which is based on a few cases done many years ago, he remarked.
Prof. Shahid Sami
In their concluding remarks by the chairpersons, the panelists stated that our mortality should be less as compared to developed centers because our number of cases are low. There is difference in data hence we must rely on our own data. Local guidelines are always important. Rheumatic is our problem and we should be writing about it.
Second Session
Prof. Saba Bhatti from NICVD was the first speaker in this session who shared the NICVD experience of Multidisciplinary approach to complex Valvular Heart Disease. She pointed out that Valve Clinics are functioning all over the world and for managing complex cases, one needs multidisciplinary team. She discussed the model diagnostic investigations, contemporary management of complex valvular diseases. At times these patients, she opined, are mistreated, people are reluctant to share data. Education of the patient is important. She then talked about pre-operative examination, follow up and contact with the physician. All physicians in the Valve Clinic at NICVD sit together and examine the patient same day. All patients are individualized as one should aim to treat the patient not the disease. Hence individualized treatment is planned.
Prof. Jawaid Akbar Sial
Before the start of valve clinic, people were not talking to each other. We established this Valve Clinic in September 2022 and started with three half days a week. Administration was kind enough to provide us special area for the Valve Clinic. We discuss and debate about each patient. Speaking about the burden of valve heart disease in Pakistan she said that so far we have examined three thousand twenty patients. About 30% were bicuspid valve. Rheumatic Heart Disease is most common. Co-morbidities include diabetes and hypertension. Out of these two thousand two hundred patients were referred for surgery. Five hundred valvular heart surgery were done. During the last two years, about seven hundred surgeries for valvular heart diseases were performed and these patients are followed up. We were able to save 25% patients from surgeons, she added.
Prof. Babar Hassan along with Dr. Shazia Mohsin making a presentation
at the Pakistan Heart Valve Cardiac Imaging 2025.
Prof. Shahid Sami a noted Cardiac Surgeon was the next speaker who talked about Rheumatic Mitral Valve Disease: Repair vs Replacement. He was of the view that every effort should be made to repair the valve rather than opting for replacement. We have many centers and we can have specialized centers doing repair. We have over three hundred thousand patients with rheumatic heart disease and it is most common under twenty-five years of age. Hence we need specialized centers for this in the country. He also talked about ideal heart valve quality and opined that one should optimize valve selection, keep in mind the wear and tear and calcification. Valve repair is not possible in old children. He emphasized the importance of valve repair which should be the first choice and one can save the patients from anticoagulation therapy. He then discussed the strategy for holistic repair. Knowledge of anatomy, he said, was extremely important and then referred to different stages of repair.
Prof. Col. Sajjad Hussain
Debate on TAVR vs SAVR
This was followed by an interesting debate on TAVR vs SAVR in which Dr. Bashir Hanif from Tabba Heart Institute and Prof. Saulat Fatimi from Aga Khan University participated.
Dr. Bashir Hanif pointed out that TAVR is expanding. Aortic stenosis is life threatening if not treated. TAVR is better than SAVR. Patient goes home the next day. TAVR was started in 2002. It is safe and effective. It ensures fast recovery and is good for Low and Middle Income countries. Stroke mortality in TAVR and SAVE is equal. TAVR is being increasingly performed in India and China. TAVR is now being performed on young patients in USA. In Pakistan since life expectancy is less than the developed world, we can perform it in relatively young patients. In the days to come the cost of equipment is going to come down and now economically priced valves are available from India and China as well. He then jokingly remarked that we have a group of Doctors on Wheels, we go for cycling regularly and Dr. Saulat Fatimi is always behind me.
In his response, Prof.Saulat Fatimi remarked that there is a clash between ideologies. Cardiac surgeons are always behind cardiologists, just like the father is behind children to take care of them. He further stated that TAVR was just like driving Tesla in Orangi Town. TAVR was initially for elderly people and we agreed to that but then like the Arabian Camel, the cardiologists started encroaching further deeper. They even started doing TAVR in low risk cases and we are against that. Will it work in long term is not sure? SAVR is good for Low and Middle Income Countries as we have young patients. They have to live for more than twenty years. TAVR cannot ensure long term durability. SAVR has warranty. One has to take care of complications and cost of healthcare sustainability. TAVR is not cost effective. It needs sophisticated infrastructure and training. We should not deny surgery to deserving patients. We need to do rational thinking and opt for cost effective sustainable procedure which is gold standard for Low and Middle Income Countries.
In his response Dr. Bashir Hanif said one should go for better options. We are not against cardiac surgeons. We have to work as a Heart Team. It should be a team work to provide best care. While TAVI is increasing, SAVR remains the same. We must also remember that we are dealing with a different population, he added.
In his concluding remarks, Dr. Khawaja Amin said that there is always room for cardiac surgeons and we have to address the comorbidities. Prof.Abdul Hakeem remarked that surgeon must say no and only then one should perform TAVR and patient’s preference must be taken into account, he remarked. Prof. Abdus Samad’s concluding remarks are covered in this issue in Off the Record column.
Third Session
Prof. Babar S. Hassan and Dr Shazia Mohsin from Sindh Institute of Urology and Transplantation made a combined presentation on “Melody vs Harmony Implantation”. They emphasized the importance of planning and imaging. They discussed management of a case with Trans catheter Valve Replacement. It was a modified harmony valve and this procedure they stated has been first of its kind in Pakistan. Melody Prof.Babar Hassan stated is on left while Harmony valve is on right. They discussed the management of three cases. They reiterated that one must ensure that imaging experts are with you throughout this procedure.
Dr. Bashir Hanif was the next speaker who spoke about Valve in Valve TMVR. This was a seventy-two years old female patient who was discharged on second day. On follow up her symptoms had improved.
Prof.Abdul Hakeem discussed ACURATE Neo2 Valve: Novel design for life time management of Aortic Stenosis. So far we have done fourteen cases and we plan to do more cases, he remarked.
Prof. Saba Bhatti along with Prof. Khawar Kazmi presenting Mementoes to the speakers at the Heart Valve Cardiac Imaging Summitt 2025.
During the discussion it was emphasized that meticulous planning and excellent imaging are extremely important. Prof. Babar Hassan was commended to have performed this procedure in a public sector hospital. We need to develop health infrastructure and local production of stents needs to be undertaken.
Fourth Session
Dr. Benoy Shah from UK made a presentation on RESHAPE-Hf2- Did it reshape the landscape for Mitral TEER in Heart Failure. He discussed the challenges of mitral regurgitation severity. One of the studies showed that 50% patients died within three years. Mortality and re-hospitalization decreased or were equal in various trials in last two years. Dr. Azam remarked that it is a bad disease while Prof. Khawar Kazmi stated that severity of the disease will determine the outcome. These are not cheap devices, he added.
Prof. Sajjad Hussain from Army Cardiac Hospital Lahore discussed the role of Cardiac CT in the evaluation of structural heart disease. It is useful in pre TAVR evaluation. He also talked about LAA occlusion. He then discussed Trans catheter MV replacement. He also discussed factors which influence replacement. Prof.Khawar Kazmi remarked that imaging is extremely important while another panelist stated that role of planning in CT images was also important.
Doctors on the Wheels, Dr. Bashir Hanif and Prof. Saulat Fatimi who participated in the Debate on TAVR vs SAVR during the Pakistan Heart Valve Cardiac Imaging Summit held recently.
Prof.Saba Bhatti’s shared the data of one year of CMR at National Institute of Cardiovascular Diseases. She emphasized that one must look for appropriate criteria, guidelines. It is very useful in congenital heart disease, Amyloid, pericardial conditions, myocarditis, it is a very expensive machine and this facility is only available at another private hospital. She then showed a long list of indications for CMR. Personnel she opined, needs lot of training. One has to be careful in patients with kidney disease, fibrosis, pace makers. Reading of the images by radiologists and cardiologists are different. One has to narrow it down and be specific to get more information. So far we have done about six hundred cases. Many patients are miss-diagnosed in Pakistan. She concluded her presentation by discussing different cases.
Prof. Saba Bhatti Chief Organizer and Course Director of 3rd Pakistan Heart Valve Cardiac Imaging Summit 2025 organized by NICVD photographed along with other staff members who were involved in the organization of the Summit.
In the last session three presentations were scheduled and the topics were 4D Echo innovations for 4D structural Heart Interventions by Jawdat Sanuri, Beyond Echo: The expanding role of Multimodality Imaging Evaluation of Valvular Heart Disease by Dr. Wajid Hussain and 3D TEE: An essential tool for the evaluation of Valvular Heart Disease in 2025 by Dr. M. Faizan Siddiqui.
